The paperless general practice

It is coming, but needs more professional input

The contract between health commissioning authorities and general practitioners states that “a doctor shall keep adequate records of the illness and treatment of his patients on forms supplied to him for the purpose.” “Form” is clearly a paper form, yet in 1993 a large national survey found that 8% of general practices were already paperless.1 The regulations will probably soon be changed to remove the limitation on paperless records. Are general practitioners and their clinical information systems ready for this legitimisation?

Certainly electronic medical records have been admissible in medical litigation and criminal cases for some years,2 though the Civil Evidence Act requires that the computer system should be created for the purpose that it is being used; there should be proper hardware and software maintenance; electronic records should be contemporaneous; and there should be a full audit trail of additions and deletions. The required audit trails are specified in version 3 of the requirements for accreditation for general practice computer systems,3 and most systems now conform to at least these sections. Furthermore, there is …